Hospital Frequent Flyers: The North Texas Solution

CCI took advantage of a Centers for Medicare and Medicaid Services program called Accountable Health Communities, created to address social determinants of health and reduce hospital utilization. These communities consist of health systems and community-based organizations. In North Texas, PCCI helped bring together Parkland Health, Baylor Scott & White Health, Children’s Health, Methodist Health System, and Metrocare Services joined with more than 100 community-based organizations and the Texas Health and Human Services Commission to provide wrap-around service to Dallas residents who live in ZIP codes with lower social determinants of health.

The results of this five-year initiative were recently published in the New England Journal of Medicine. During that time, the partnership screened 12,548 high-risk Medicare and Medicaid individuals and identified 19,000 distinct needs, with 61 percent of the individuals having more than one need. The organizations worked together to serve those needs and gave out 200,000 pounds of food and $540,000 in utility and rent assistance.